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HWN Suggests

Some New Perspectives on Vasopressors for Septic Shock

Although standard practice on sepsis management includes source control, early antibiotics, IV fluids until optimal intravascular volume is achieved (usually initiated as a 30cc/kg IV fluids), and to initiate vasopressors only after MAPs remain refractory to these measures, a recent study from 2019, the CENSER trial, evaluated the benefit of initiating norepinephrine even earlier. This single-center, randomized, double blind, placebo-controlled trial randomized patients to either receive standard treatment plus norepinephrine at an untitrated fixed rate of 0.05mcg/kg/min via either central or peripheral access or receive standard treatment plus a placebo infusion.

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 A Paradigm shift: re-thinking sepsis, and maybe shock in general

My (very) humble opinion on this is a rather simple, almost philosophical one: why are we seemingly obsessed with treating a predominantly vasodilatory pathology with large amounts of volume? I’ve said this in previous posts and podcasts, but this, in my opinion, is largely cultural and dogmatic. “Levophed – Leave’em dead” is something I heard as a student and resident, and came to take for granted that I should give lots of fluid in hopes of avoiding pressors… But there’s no evidence at all to support this.

 The New Goal in Goal-Directed Sepsis Therapy: Pink Pinkies

There’s a new goal in goal-directed therapy for sepsis, and it’s right at your fingertips. It works as well as any other, which is to say, not very well. Capillary refill time is a fast and easy test to assess peripheral perfusion. It’s now been tested as a primary endpoint of resuscitation for septic shock in two multicenter international trials.

Articles of Interest

Catecholamines helpful or harmful in critical illness?

Despite high catecholamines in sepsis, blood pressure is often low in septic shock. One reason for low blood pressure in sepsis is activation of inducible nitric oxide synthase... along with depressed cardiac contractility... In response to low blood pressure, clinicians attempt to fix the problem by giving catecholamine vasopressors – most often norepinephrine. These come with some unintended consequences, and recent studies suggest that infusing catecholamine vasopressors harms some patients.

Resus of the hypotensive patient Part 1 - When IV Fluids Kill

There is probably no other drug emergency providers administer more often than IV fluids. We give them to patients with mild heat exhaustion, gastroenteritis and orthostatic dizziness to name a few. These patients tend to feel better, go home and no harm comes to them. However, for the subset of patients with shock and potential recipients of large volume resuscitation, excessive IV fluids can harm.

Sepsis: What Works, What Doesn't?

Central lines are no longer thought to be mandatory for all sepsis patients, Dr. Whittle said. “We now have solid data saying that high-quality peripheral lines are safe for administration of low-dose vasopressors for a limited time. Now, if your patient is going to need pressors longer than that, or if they're going to need more ports than you can get in a peripheral line because you're administering numerous meds, sometimes you will need a central line. Over the last few years, my practice has evolved to where I initiate pressors more quickly and allow less hypotension, preferably almost none, but I initiate far fewer central lines.”

Bacteria. A Story about Septic Shock

Over the next couple of days in his confused, semi-conscious daze, he hears the voices of doctors and nurses and constant beeps of medical monitors. Henry doesn’t know it, but he was rushed to the hospital after his alert doctor diagnosed a rare condition. The blood in the spaces below his brain clotted and the infection started flowing over into his blood stream – a condition called “septic shock”.

Fluids in Sepsis, A New Paradigm

Dr. Paul Marik is a renowned intensivist and a confirmed critical care skeptic. He has broken down many myths such as the use of CVP for volume assessment.

Pediatric Sepsis and Septic Shock

Kids aren’t little adults. Pediatric sepsis and septic shock usually presents as ‘cold shock’ where as adult septic shock usually presents as ‘warm shock’, for example.

Sepsis and septic shock: current approaches to management

Sepsis, defined as life‐threatening organ dysfunction due to a dysregulated host response to infection, is recognised by the World Health Organization as a global health priority.

Septic shock: Rapid recognition and initial resuscitation in children

The use of colloid for fluid resuscitation for children with septic shock is controversial. Nevertheless, colloid infusion with albumin 5 percent is a reasonable option for children who have not improved following >60 mL/kg of crystalloid fluid, have hypoalbuminemia (albumin <3 g/dL), or who develop a hyperchloremic metabolic acidosis.

Shock, Sepsis, and Multiple Organ Dysfunction Syndrome

Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic, and hemodynamic alterations. Ineffective tissue perfusion occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demand. This imbalance can occur for a variety of reasons and eventually results in cellular dysfunction and death.

Treatment of Patients with Severe Sepsis and Septic Shock: Current Evidence-Based Practices

Management of sepsis and septic shock involves early interventions to achieve hemodynamic stability. Due to the heterogeneity and complexity of sepsis pathophysiology, there is no perfect therapy for sepsis that “fits for all.” However, implementation of best-practice guidelines based on evidence-based medicine has shown to improve mortality associated with sepsis and septic shock. Many elements of the guidelines remain controversial and more research is needed to address these important unanswered questions.

Updates and Controversies in the Early Management of Sepsis and Septic Shock

This issue of Emergency Medicine Practice reviews the recent changes in sepsis criteria, prognosticators, and quality metrics and offers recommendations on the recognition and treatment of sepsis, severe sepsis, and septic shock in the emergency department.

Vitamin C, hydrocortisone, and thiamine for severe sepsis and septic shock

I can’t help but compare this protocol to the VSE (vasopressin+steroids+epinephrine) protocol in cardiac arrest. The VSE protocol was subjected to a randomized controlled trial in 2009 and again in 2013. The effects of VSE were dramatic.

What are septic shock and sepsis? The facts behind these deadly conditions

It can be difficult to distinguish sepsis from other diseases that can make one very sick, and there is no lab test that can confirm sepsis. Many conditions can mimic sepsis, including severe allergic reactions, bleeding, heart attacks, blood clots and medication overdoses. Sepsis requires particular prompt treatments, so getting the diagnosis right matters.